A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Administer intravenous pain medication.
Draw blood for a complete blood cell (CBC) count.
Insert an indwelling urinary catheter.
Inspect the mouth for signs of inhalation injuries.
The Correct Answer is D
Choice A Reason: This choice is incorrect because administering intravenous pain medication is not the priority action for a client who has sustained partial-thickness burns. Pain medication may be indicated for pain relief and comfort, but it does not address the potential life-threatening complications of burns such as shock, infection, or respiratory distress.
Choice B Reason: This choice is incorrect because drawing blood for a CBC count is not the priority action for a client who has sustained partial-thickness burns. A CBC count may be useful to monitor the hematological status and detect any signs of infection or anemia, but it does not address the immediate needs of the client
Choice C Reason: This choice is incorrect because inserting an indwelling urinary catheter is not the priority action for a client who has sustained partial-thickness burns. A urinary catheter may be necessary to measure the urine output and assess the renal function and fluid balance, but it does not address the most urgent problem of the client.
Choice D Reason: This choice is correct because inspecting the mouth for signs of inhalation injuries is the priority action for a client who has sustained partial-thickness burns. Inhalation injuries are caused by inhaling hot air, smoke, or toxic gases that damage the airway and lungs. They can cause airway obstruction, bronchospasm, pulmonary edema, or respiratory failure. Therefore, the nurse should inspect the mouth for signs such as soot, singed nasal hairs, burns on the lips or tongue, hoarseness, stridor, or wheezes. The nurse should also monitor the oxygen saturation and arterial blood gases to assess the oxygenation and ventilation status of the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Step 1: Determine the total time required to infuse 40 mEq at a rate of 10 mEq/hr.
40 mEq ÷ 10 mEq/hr = 4 hours
Result: 4 hours
Step 2: Determine the infusion rate in mL/hr.
500 mL ÷ 4 hours = 125 mL/hr
Result: 125 mL/hr
The nurse should set the IV pump to deliver 125 mL/hr.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because crepitus in the area above and surrounding the insertion site is not a serious finding that requires notification of the provider. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It is usually harmless and resolves on its own.
Choice B reason: This is incorrect because bubbling of the water in the water seal chamber with exhalation is a normal finding that indicates that air is being removed from the pleural space. Bubbling should stop when the pneumothorax is resolved.
Choice C Reason: This is incorrect because eyelets are not visible is not a serious finding that requires notification of the provider. Eyelets are small holes at the end of the chest tube that allow air and fluid to drain from the pleural space. They are usually covered by a dressing and may not be visible.
Choice D Reason: This is correct because movement of the trachea toward the unaffected side is a serious finding that indicates a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and causes pressure on the mediastinum. The nurse should notify the provider immediately and prepare for needle decompression or chest tube insertion.
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